State of Illinois
90th General Assembly
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90_HB3581

      305 ILCS 5/5-5            from Ch. 23, par. 5-5
          Amends the  Illinois  Public  Aid  Code.   In  provisions
      outlining  the  medical services to be covered for recipients
      of medical assistance under the Code provides that  in  order
      to ensure patient freedom of choice, the Department of Public
      Aid shall immediately promulgate all rules and take all other
      necessary  actions  so that provided services may be accessed
      from  therapeutically  certified  optometrists  to  the  full
      extent of  the  Illinois  Optometric  Practice  Act  of  1987
      without  discrimination  from  other  like service providers.
      Effective immediately.
                                                    LRB9008317SMdvA
                                              LRB9008317SMdvA
 1        AN ACT to amend the Illinois Public Aid Code by  changing
 2    Section 5-5.
 3        Be  it  enacted  by  the People of the State of Illinois,
 4    represented in the General Assembly:
 5        Section 5.  The Illinois Public Aid Code  is  amended  by
 6    changing Section 5-5 as follows:
 7        (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
 8        Sec.  5-5.  Medical services. The Illinois Department, by
 9    rule, shall determine the quantity and  quality  of  and  the
10    rate  of  reimbursement  for the medical assistance for which
11    payment will be authorized, and the medical  services  to  be
12    provided, which may include all or part of the following: (1)
13    inpatient   hospital   services;   (2)   outpatient  hospital
14    services;  (3)  other  laboratory  and  X-ray  services;  (4)
15    skilled  nursing  home  services;  (5)  physicians'  services
16    whether furnished  in  the  office,  the  patient's  home,  a
17    hospital,  a  skilled nursing home, or elsewhere; (6) medical
18    care, or  any  other  type  of  remedial  care  furnished  by
19    licensed  practitioners;  (7)  home health care services; (8)
20    private duty  nursing  service;  (9)  clinic  services;  (10)
21    dental  services; (11) physical therapy and related services;
22    (12) prescribed drugs, dentures, and prosthetic devices;  and
23    eyeglasses  prescribed by a physician skilled in the diseases
24    of the eye, or by an optometrist, whichever  the  person  may
25    select;  (13)  other  diagnostic,  screening, preventive, and
26    rehabilitative services; (14) transportation and  such  other
27    expenses  as  may  be  necessary;  (15)  medical treatment of
28    sexual assault survivors, as defined in  Section  1a  of  the
29    Sexual   Assault   Survivors  Emergency  Treatment  Act,  for
30    injuries  sustained  as  a  result  of  the  sexual  assault,
                            -2-               LRB9008317SMdvA
 1    including  examinations  and  laboratory  tests  to  discover
 2    evidence which may be used in  criminal  proceedings  arising
 3    from  the sexual assault; (16) the diagnosis and treatment of
 4    sickle cell anemia; and (17) any other medical care, and  any
 5    other type of remedial care recognized under the laws of this
 6    State,  but  not including abortions, or induced miscarriages
 7    or premature births, unless, in the opinion of  a  physician,
 8    such  procedures  are  necessary  for the preservation of the
 9    life of the  woman  seeking  such  treatment,  or  except  an
10    induced  premature  birth  intended  to produce a live viable
11    child and such procedure is necessary for the health  of  the
12    mother or her unborn child. The Illinois Department, by rule,
13    shall   prohibit   any   physician   from  providing  medical
14    assistance to anyone eligible therefor under this Code  where
15    such  physician  has  been  found  guilty  of  performing  an
16    abortion procedure in a wilful and wanton manner upon a woman
17    who  was not pregnant at the time such abortion procedure was
18    performed. The term "any other type of remedial  care"  shall
19    include nursing care and nursing home service for persons who
20    rely on treatment by spiritual means alone through prayer for
21    healing.
22        The  Illinois  Department of Public Aid shall provide the
23    following services to persons eligible for  assistance  under
24    this  Article who are participating in education, training or
25    employment programs  operated  by  the  Department  of  Human
26    Services as successor to the Department of Public Aid:
27             (1)  dental services, which shall include but not be
28        limited to prosthodontics; and
29             (2)  eyeglasses prescribed by a physician skilled in
30        the  diseases of the eye, or by an optometrist, whichever
31        the person may select.
32        The Illinois Department, by  rule,  may  distinguish  and
33    classify   the  medical  services  to  be  provided  only  in
34    accordance with the classes of persons designated in  Section
                            -3-               LRB9008317SMdvA
 1    5-2.
 2        The Illinois Department shall authorize the provision of,
 3    and  shall  authorize  payment  for,  screening  by  low-dose
 4    mammography  for  the  presence  of  occult breast cancer for
 5    women 35 years of age or older who are eligible  for  medical
 6    assistance  under  this  Article,  as  follows:   a  baseline
 7    mammogram  for  women  35  to  39  years of age and an annual
 8    mammogram for women 40 years of age or older.  All screenings
 9    shall  include  a  physical  breast  exam,   instruction   on
10    self-examination  and  information regarding the frequency of
11    self-examination and its value as a  preventative  tool.   As
12    used  in this Section, "low-dose mammography" means the x-ray
13    examination  of  the   breast   using   equipment   dedicated
14    specifically  for  mammography,  including  the  x-ray  tube,
15    filter,  compression  device,  image receptor, and cassettes,
16    with an average radiation exposure delivery of less than  one
17    rad mid-breast, with 2 views for each breast.
18        Any  medical  or  health  care provider shall immediately
19    recommend, to  any  pregnant  woman  who  is  being  provided
20    prenatal  services  and  is  suspected  of  drug  abuse or is
21    addicted as defined in the Alcoholism and  Other  Drug  Abuse
22    and  Dependency  Act,  referral  to  a  local substance abuse
23    treatment  provider  licensed  by  the  Department  of  Human
24    Services or to a licensed hospital which  provides  substance
25    abuse treatment services.  The Department of Public Aid shall
26    assure  coverage  for the cost of treatment of the drug abuse
27    or addiction for pregnant recipients in accordance  with  the
28    Illinois  Medicaid Program in conjunction with the Department
29    of Human Services.
30        All medical providers  providing  medical  assistance  to
31    pregnant women under this Code shall receive information from
32    the Department on the availability of services under the Drug
33    Free  Families  with  a  Future  or  any  comparable  program
34    providing   case  management  services  for  addicted  women,
                            -4-               LRB9008317SMdvA
 1    including information  on  appropriate  referrals  for  other
 2    social  services  that  may  be  needed  by addicted women in
 3    addition to treatment for addiction.
 4        The  Illinois  Department,  in   cooperation   with   the
 5    Departments of Human Services (as successor to the Department
 6    of Alcoholism and Substance Abuse) and Public Health, through
 7    a   public   awareness   campaign,  may  provide  information
 8    concerning  treatment  for  alcoholism  and  drug  abuse  and
 9    addiction, prenatal health care, and other pertinent programs
10    directed at reducing the number of drug-affected infants born
11    to recipients of medical assistance.
12        Neither the Illinois Department of  Public  Aid  nor  the
13    Department  of  Human  Services  shall sanction the recipient
14    solely on the basis of her substance abuse.
15        The Illinois Department shall establish such  regulations
16    governing  the  dispensing  of  health  services  under  this
17    Article  as  it shall deem appropriate.  In formulating these
18    regulations the Illinois Department shall  consult  with  and
19    give substantial weight to the recommendations offered by the
20    Citizens  Assembly/Council  on  Public  Aid.  The  Department
21    should  seek  the  advice  of  formal  professional  advisory
22    committees   appointed   by  the  Director  of  the  Illinois
23    Department for the purpose of  providing  regular  advice  on
24    policy  and administrative matters, information dissemination
25    and  educational  activities  for  medical  and  health  care
26    providers, and consistency  in  procedures  to  the  Illinois
27    Department.
28        The  Illinois  Department  may  develop and contract with
29    Partnerships of medical providers to arrange medical services
30    for  persons  eligible  under  Section  5-2  of  this   Code.
31    Implementation  of  this  Section  may  be  by  demonstration
32    projects  in certain geographic areas.  The Partnership shall
33    be represented by a sponsor organization.  The Department, by
34    rule,  shall   develop   qualifications   for   sponsors   of
                            -5-               LRB9008317SMdvA
 1    Partnerships.   Nothing in this Section shall be construed to
 2    require  that  the  sponsor   organization   be   a   medical
 3    organization.
 4        The  sponsor must negotiate formal written contracts with
 5    medical  providers  for  physician  services,  inpatient  and
 6    outpatient hospital care, home health services, treatment for
 7    alcoholism and substance abuse, and other services determined
 8    necessary by the Illinois Department by rule for delivery  by
 9    Partnerships.   Physician  services must include prenatal and
10    obstetrical care.  The Illinois  Department  shall  reimburse
11    medical   services  delivered  by  Partnership  providers  to
12    clients in target  areas  according  to  provisions  of  this
13    Article  and  the  Illinois Health Finance Reform Act, except
14    that:
15             (1)  Physicians participating in a  Partnership  and
16        providing  certain services, which shall be determined by
17        the Illinois Department, to persons in areas  covered  by
18        the  Partnership  may receive an additional surcharge for
19        such services.
20             (2)  The  Department  may  elect  to  consider   and
21        negotiate   financial   incentives   to   encourage   the
22        development of Partnerships and the efficient delivery of
23        medical care.
24             (3)  Persons   receiving  medical  services  through
25        Partnerships may  receive  medical  and  case  management
26        services  above  the  level  usually  offered through the
27        medical assistance program.
28        Medical providers  shall  be  required  to  meet  certain
29    qualifications  to  participate in Partnerships to ensure the
30    delivery   of   high   quality   medical   services.    These
31    qualifications shall be determined by rule  of  the  Illinois
32    Department   and   may  be  higher  than  qualifications  for
33    participation in the medical assistance program.  Partnership
34    sponsors may prescribe reasonable  additional  qualifications
                            -6-               LRB9008317SMdvA
 1    for  participation  by medical providers, only with the prior
 2    written approval of the Illinois Department.
 3        Nothing in this Section shall limit the  free  choice  of
 4    practitioners,  hospitals,  and  other  providers  of medical
 5    services by clients. In order to ensure  patient  freedom  of
 6    choice,  the Illinois Department shall immediately promulgate
 7    all rules and  take  all  other  necessary  actions  so  that
 8    provided   services  may  be  accessed  from  therapeutically
 9    certified optometrists to the full  extent  of  the  Illinois
10    Optometric  Practice  Act of 1987 without discrimination from
11    other like service providers.
12        The Department shall apply for a waiver from  the  United
13    States  Health Care Financing Administration to allow for the
14    implementation of Partnerships under this Section.
15        The  Illinois  Department  shall  require   health   care
16    providers  to maintain records that document the medical care
17    and services provided to  recipients  of  Medical  Assistance
18    under  this  Article.   The Illinois Department shall require
19    health care providers to make available, when  authorized  by
20    the  patient,  in  writing,  the  medical records in a timely
21    fashion to other health care providers who  are  treating  or
22    serving  persons  eligible  for Medical Assistance under this
23    Article.   All  dispensers  of  medical  services  shall   be
24    required  to  maintain  and  retain business and professional
25    records sufficient  to  fully  and  accurately  document  the
26    nature,  scope,  details  and  receipt  of  the  health  care
27    provided  to  persons  eligible  for medical assistance under
28    this Code, in accordance with regulations promulgated by  the
29    Illinois  Department. The rules and regulations shall require
30    that proof of the receipt of  prescription  drugs,  dentures,
31    prosthetic  devices  and eyeglasses by eligible persons under
32    this Section accompany each claim for reimbursement submitted
33    by the dispenser of such medical services. No such claims for
34    reimbursement shall be approved for payment by  the  Illinois
                            -7-               LRB9008317SMdvA
 1    Department without such proof of receipt, unless the Illinois
 2    Department  shall have put into effect and shall be operating
 3    a system of post-payment audit and review which shall,  on  a
 4    sampling basis, be deemed adequate by the Illinois Department
 5    to  assure  that such drugs, dentures, prosthetic devices and
 6    eyeglasses for which payment is being made are actually being
 7    received by eligible recipients. Within  90  days  after  the
 8    effective  date  of this amendatory Act of 1984, the Illinois
 9    Department shall establish  a  current  list  of  acquisition
10    costs   for  all  prosthetic  devices  and  any  other  items
11    recognized as medical  equipment  and  supplies  reimbursable
12    under  this Article and shall update such list on a quarterly
13    basis, except that the acquisition costs of all  prescription
14    drugs  shall be updated no less frequently than every 30 days
15    as required by Section 5-5.12.
16        The rules and  regulations  of  the  Illinois  Department
17    shall require that a written statement including the required
18    opinion   of  a  physician  shall  accompany  any  claim  for
19    reimbursement  for  abortions,  or  induced  miscarriages  or
20    premature  births.   This  statement  shall   indicate   what
21    procedures were used in providing such medical services.
22        The Illinois Department shall require that all dispensers
23    of medical services, other than an individual practitioner or
24    group  of  practitioners,  desiring  to  participate  in  the
25    Medical  Assistance program established under this Article to
26    disclose all financial, beneficial, ownership, equity, surety
27    or other  interests  in  any  and  all  firms,  corporations,
28    partnerships,   associations,   business  enterprises,  joint
29    ventures, agencies,  institutions  or  other  legal  entities
30    providing  any  form  of  health  care services in this State
31    under this Article.
32        The Illinois Department may require that  all  dispensers
33    of  medical  services  desiring to participate in the medical
34    assistance program established under this  Article  disclose,
                            -8-               LRB9008317SMdvA
 1    under  such  terms  and conditions as the Illinois Department
 2    may  by  rule  establish,  all  inquiries  from  clients  and
 3    attorneys  regarding  medical  bills  paid  by  the  Illinois
 4    Department,  which   inquiries   could   indicate   potential
 5    existence of claims or liens for the Illinois Department.
 6        The   Illinois   Department   shall  establish  policies,
 7    procedures,  standards  and  criteria   by   rule   for   the
 8    acquisition,   repair   and   replacement   of  orthotic  and
 9    prosthetic devices and durable medical equipment.  Such rules
10    shall provide, but not be limited to, the following services:
11    (1) immediate  repair  or  replacement  of  such  devices  by
12    recipients  without  medical  authorization;  and (2) rental,
13    lease,  purchase  or  lease-purchase   of   durable   medical
14    equipment   in   a   cost-effective   manner,   taking   into
15    consideration  the  recipient's medical prognosis, the extent
16    of the recipient's needs, and the requirements and costs  for
17    maintaining  such  equipment.   Such  rules  shall  enable  a
18    recipient  to  temporarily  acquire  and  use  alternative or
19    substitute  devices   or   equipment   pending   repairs   or
20    replacements of any device or equipment previously authorized
21    for  such recipient by the Department. Rules under clause (2)
22    above shall not provide for  purchase  or  lease-purchase  of
23    durable medical equipment or supplies used for the purpose of
24    oxygen delivery and respiratory care.
25        The  Department  shall  execute,  relative to the nursing
26    home prescreening project,  written  inter-agency  agreements
27    with  the  Department of Human Services and the Department on
28    Aging, to effect the following:  (i)  intake  procedures  and
29    common   eligibility  criteria  for  those  persons  who  are
30    receiving   non-institutional   services;   and   (ii)    the
31    establishment  and  development of non-institutional services
32    in areas of the State where they are not currently  available
33    or are undeveloped.
34        The  Illinois  Department  shall  develop and operate, in
                            -9-               LRB9008317SMdvA
 1    cooperation with other State Departments and agencies and  in
 2    compliance  with  applicable  federal  laws  and regulations,
 3    appropriate and effective systems of health  care  evaluation
 4    and  programs  for  monitoring  of utilization of health care
 5    services and facilities, as it affects persons  eligible  for
 6    medical  assistance  under this Code. The Illinois Department
 7    shall report regularly the results of the operation  of  such
 8    systems  and  programs  to  the  Citizens Assembly/Council on
 9    Public Aid to enable the Committee to ensure,  from  time  to
10    time, that these programs are effective and meaningful.
11        The  Illinois  Department  shall  report  annually to the
12    General Assembly, no later than the second Friday in April of
13    1979 and each year thereafter, in regard to:
14             (a)  actual statistics and trends in utilization  of
15        medical services by public aid recipients;
16             (b)  actual  statistics  and trends in the provision
17        of the various medical services by medical vendors;
18             (c)  current rate structures and proposed changes in
19        those rate structures for the  various  medical  vendors;
20        and
21             (d)  efforts  at  utilization  review and control by
22        the Illinois Department.
23        The period covered by each report shall be  the  3  years
24    ending  on the June 30 prior to the report.  The report shall
25    include  suggested  legislation  for  consideration  by   the
26    General  Assembly.  The filing of one copy of the report with
27    the Speaker, one copy with the Minority Leader and  one  copy
28    with the Clerk of the House of Representatives, one copy with
29    the President, one copy with the Minority Leader and one copy
30    with   the  Secretary  of  the  Senate,  one  copy  with  the
31    Legislative Research Unit, such additional  copies  with  the
32    State  Government  Report Distribution Center for the General
33    Assembly as is required under paragraph (t) of Section  7  of
34    the  State  Library  Act  and  one  copy  with  the  Citizens
                            -10-              LRB9008317SMdvA
 1    Assembly/Council  on  Public  Aid  or  its successor shall be
 2    deemed sufficient to comply with this Section.
 3    (Source:  P.A.  89-21,  eff.  7-1-95;  89-507,  eff.  7-1-97;
 4    89-517, eff. 1-1-97; 90-7, eff. 6-10-97; 90-14, eff. 7-1-97.)
 5        Section 99.  Effective date.  This Act takes effect  upon
 6    becoming law.

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